Healthcare Provider Details

I. General information

NPI: 1043741507
Provider Name (Legal Business Name): ADAM J HAGGERTY D.O.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/25/2017
Last Update Date: 06/02/2026
Certification Date: 06/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD
GREEN BAY WI
54311-6519
US

IV. Provider business mailing address

1035 KEPLER DR
GREEN BAY WI
54311-8320
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-8377
  • Fax: 920-288-8385
Mailing address:
  • Phone: 920-490-9046
  • Fax: 920-405-8005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208VP0014X
TaxonomyInterventional Pain Medicine Physician
License Number70302-21
License Number StateWI
# 2
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number70302
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: